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The Health Collaborative’s ED Care Coordination Pathway

Ohio

The Health Collaborative’s ED Care Coordination Pathway serves ED super-utilizers by assigning them a community health worker who coordinates services related to patients' medical, social and behavioral health needs. Coordination services include helping a patient establish a relationship with a primary care provider, find a medical home, secure transportation to and from appointments and find stable housing.
Partner Organizations	The Health Collaborative Health Care Access Now 10 regional hospitals
Target Population	Individuals (primarily Medicaid enrollees, dual-eligibles and the uninsured) with 20 or more ED visits in the past 12 months
Care Team	Community-based outreach team that includes a community health worker and AmeriCorps volunteers; multidisciplinary clinical advisory team composed of physicians, a hospital case manager, a social worker and a behavioral health professional
Timeframe	2012 - 2014
Results/ Studies	ED visits for patients in the program for 6 months or longer decreased by 54 percent. ED-related charges declined by 62 percent.
Funding	Private grants
Resources	Robert Wood Johnson Foundation program description Program video Presentation by Health Care Access Now (PDF)